S.B. 57
This document includes Senate 2nd Reading Floor Amendments incorporated into the bill on Wed, Feb 26, 2014 at 4:58 PM by lpoole. --> 1
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7 LONG TITLE
8 General Description:
9 This bill amends the Insurance Code to provide health benefit plan coverage for the
10 treatment of autism spectrum disorder.
11 Highlighted Provisions:
12 This bill:
13 . defines terms;
14 . requires a health benefit plan to provide coverage for the treatment of autism
15 spectrum disorder;
16 . grants rulemaking authority to the insurance commissioner;
17 . describes minimum coverage amounts and limits for the insurance coverage;
18 . provides for the annual adjustment of the coverage amounts based on the Consumer
19 Price Index; and
20 . provides an exemption for small employers if premium costs increase by more than
21 a certain percentage.
22 Money Appropriated in this Bill:
23 None
24 Other Special Clauses:
25 None
26 Utah Code Sections Affected:
27 ENACTS:
Senate 2nd Reading Amendments 2-26-2014 lp/cjd
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31A-22-642, Utah Code Annotated 195328
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30 Be it enacted by the Legislature of the state of Utah:
31 Section 1. Section 31A-22-642 is enacted to read:
32 31A-22-642. Insurance coverage for autism spectrum disorder.
33 (1) As used in this section:
34 (a) "Applied behavior analysis" means the design, implementation, and evaluation of
35 environmental modifications, using behavioral stimuli and consequences, to produce socially
36 significant improvement in human behavior, including the use of direct observation,
37 measurement, and functional analysis of the relationship between environment and behavior.
38 (b) "Autism spectrum disorder" means any of the pervasive developmental disorders or
39 autism spectrum disorders as defined by S. [
39a Diagnostic and
40 Statistical Manual of Mental Disorders (DSM).
41 (c) "Behavioral health treatment" means counseling and treatment programs, including
42 applied behavior analysis, that are:
43 (i) necessary to develop, maintain, or restore, to the maximum extent practicable, the
44 functioning of an individual; and
45 (ii) provided or supervised by a:
46 (A) board certified behavior analyst; or
47 (B) S. [
48 psychologist's formal university training and supervised experience
48a 58, Division of Occupational and Professional Licensing, whose scope of practice includes
48b mental health services .S .
49 (d) "Diagnosis of autism spectrum disorder" means medically necessary assessments,
50 evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.
51 (e) "Pharmacy care" means medications prescribed by a licensed physician and any
52 health-related services considered medically necessary to determine the need or effectiveness
53 of the medications.
54 (f) "Psychiatric care" mea ns direct or consultative services provided by a psychiatrist
55 licensed in the state in which the psychiatrist practices.
56 (g) "Psychological care" means direct or consultative services provided by a
57 psychologist licensed in the state in which the psychologist practices.
58 (h) "Therapeutic care" means services provided by licensed or certified speech
Senate 2nd Reading Amendments 2-26-2014 lp/cjd
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therapists, occupational therapists, or physical therapists.59
60 (i) "Treatment for autism spectrum disorder":
61 (i) means evidence-based care and related equipment prescribed or ordered for an
62 individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed
63 psychologist who determines the care to be medically necessary; and
64 (ii) includes:
65 (A) behavioral health treatment, provided or supervised by a person described in
66 Subsection (1)(c)(ii);
67 (B) pharmacy care;
68 (C) psychiatric care;
69 (D) psychological care; and
70 (E) therapeutic care.
71 (2) Notwithstanding the provisions of Section 31A-22-618.5 , a health benefit plan
72 entered into or renewed on or after July 1, S. [
72a S. diagnosis and .S treatment of
73 autism spectrum disorder in accordance with the requirements of this section and the rules
74 made by the commissioner under this section.
75 (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah
76 Administrative Rulemaking Act, to set the minimum standards of coverage for the treatment of
77 autism spectrum disorder.
78 (4) Subject to Subsection (5), the rules described in Subsection (3) shall establish
79 durational limits, amount limits, deductibles, copayments, and coinsurance for the treatment of
80 autism spectrum disorder that are similar to, or identical to, the coverage provided for other
81 illnesses or diseases.
82 (5) (a) Subject to Subsection (6), coverage for behavioral health treatment for a person
83 with an autism spectrum disorder is subject to a maximum benefit of:
84 (i) $36,000 annually for a child who is younger than nine years old; and
85 (ii) $18,000 annually for a child who is at least nine years old, but younger than 18
86 years old.
87 (b) A health benefit plan providing treatment under Subsection (5)(a) shall include in
88 the plan's provider network both board certified behavior analysts and psychologists qualified
89 under Subsection (1)(c)(ii).
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91 amounts described in Subsection (5) by a percentage equal to the percentage difference
92 between the Consumer Price Index for the current calendar year and the Consumer Price Index
93 for the preceding calendar year.
94 (7) The commissioner shall grant a small employer with a group health benefit plan a
95 waiver from the provisions of this section if the small employer demonstrates to the
96 commissioner by actual claims experience over any consecutive 12-month period that
97 compliance with this section has increased the cost of the health benefit plan by an amount of
98 2-1/2% or greater over the period of a calendar year in premium costs to the small employer.
Legislative Review Note
as of 2-5-14 6:19 PM